Moonland Ladakh is located at the altitudes ranging from 9,000 (2700m) to 18,500 (5640m) feet above sea level.

Traveling to this high altitude in a short time can lead to acute health problems.

Acute Mountain Sickness (AMS) is commonly manifested as headache and vomiting. Other symptoms include breathlessness, sleeplessness
and cough. Sudden induction to such high altitude has profound effect on the body. It can lead to hypertension, blood coagulation disorders (intravascular blood coagulation, thrombo-embolism) and
pulmonary hypertension.

The risk of high altitude illness depends on how quickly one ascends to high altitude:

The recommendation is that one can safely ascend from sea level to 8,000 feet (2400m) above sea level in 24hours. Beyond this one should not ascend more
than 1,000 feet (300 meters) in 24 hours.

But, in practice this is difficult to follow. Traveling by road is therefore, considered safer which gives ample time for the body to get adjusted to altitude. Return by plane to lower altitudes
is no problem. Most serious problems include pulmonary edema, cerebral edema and thrombo-embolism. Pulmonary edema is manifested as severe breathlessness cough and frothy expectoration. If
someone has staggering gait like drunk, headache, vomiting and sleepiness it could be due to cerebral edema. Thrombo-embolism can lead to acute pain in abdomen due to splenic infarction or
intestinal ischemia. Sudden visual loss in one eye, usually transient, have been frequently encountered. Rarely lung infarction and venous sinus thrombosis in brain occur as severe consequences
of thrombo-embolism. Some cases of myocardial infarction may also be the result of high altitude. Rise of blood pressure by 20-30 mm Hg diastolic blood pressure is a common observation.

One very important consideration is the presence of risk factors in the travelers:

Hypertension, diabetes and compromised lung function or heart disease are risk factors, which can lead to Acute Mountain Sickness. More importantly, acute illnesses like flue, gastroenteritis and
fever are the precipitating factors for high altitude illness.

It is absolutely important to be aware of these symptoms and to seek medical assistance quickly in the cases of AMS.

The following symptoms must warrant urgent medical assistance:

1. Severe Breathlessness

2. Headache

3. Vomiting

4. Ataxia

5. Staggering gait (like drunk)

6. Sleepiness

7. Unconsciousness

8. Pain abdomen

9. Visual Disturbances

There are many centers around Ladakh providing health care facilities. Major centers are the district hospitals of Leh and Kargil.
Other hospitals are sub-district Hospitals at Drass, Deskit (Ph. 01982-220045), Khalsi, Padum and Primary Health centers around Ladakh. The army has many centers and major hospitals around Ladakh
and emergency services are provided freely.

FIRST AID - ALTITUDE SICKNESS

Above 3000m (some say 2500m), current best practice advice for a healthy adult dictates no more than a 300m increase in sleeping altitude per day with a
rest day every third day.

This does not mean you can't ascend more than 300m in a day, as long as you descend again before sleeping. Following this principle,
an ascent of a 6000m peak starting at around 3000m should take 10 days. However in many cases individuals will attempt such an ascent much more quickly, often leading to altitude sickness.

Normal Acclimatization

Acclimatization is the process of the body adjusting to the decreased availability of oxygen at high altitudes. It is a slow process, taking place over a
period of days to weeks. High altitude is defined as:

Certainl normal physiologic changes occur in every person who goes to altitude:

• Hyperventilation (breathing faster, deeper, or both)

• Shortness of breath during exertion

• Changed breathing pattern at night

• Awakening frequently at night

• Increased urination

As one ascends through the atmosphere, barometric pressure decreases and thus every breath contains fewer and fewer molecules of
oxygen. One must work harder to obtain oxygen, by breathing faster and deeper. This is particularly noticeable with exertion, such as walking uphill. Being out of breath with
exertion is normal, as long as the sensation of shortness of breath resolves rapidly with rest. The increase in breathing is critical. It is therefore
important to avoid anything that will decrease breathing, e.g. alcohol and certain drugs.

Despite the increased breathing, attaining normal blood levels of oxygen is not possible at high altitude. Persistent increased breathing results in reduction of
carbon dioxide in the blood, a metabolic waste product that is removed by the lungs.The build-up of carbon dioxide in the blood is the key signal
to the brain that it is time to breathe, so if it is low, the drive to breathe is blunted (the lack of oxygen is a much weaker signal, and acts as an ultimate safety valve).
As long as you are awake it is not much trouble to consciously breathe, but at night an odd breathing pattern develops due to a back-and-forth balancing act between these two respiratory
triggers. Periodic breathing consists of cycles of normal breathing which gradually slows, breath-holding, and a brief recovery period of accelerated breathing. The breath-holding may last up to
10-15 seconds. This is not altitude sickness. It may improve slightly with acclimatization, but does not usually resolve until descent. Periodic breathing can cause a lot of anxiety. If periodic
breathing symptoms are troublesome, a medication called Acetazolamide maybe helpful.

Dramatic changes take place in the body's chemistry and fluid balance during acclimatization. The osmotic centre, which detects the
concentration of the blood, gets reset so that the blood is more concentrated. This results in an altitude diuresis as the kidneys excrete more fluid. The reason for this reset is not understood,
though it has the effect of increasing the concentration of red blood cells and perhaps improving the blood's oxygen-carrying ability somewhat; it also counteracts the tendency for oedema
formation. It is normal at altitude to be urinating more than usual. If you are not, you maybe dehydrated, or you may not be acclimatizing
well.

ACUTE MOUNTAIN SICKNESS (AMS)

Acute Mountain Sickness is a constellation of symptoms that represents your body not being acclimatized to its current altitude. As you ascend, your body
acclimatizes to the decreasing oxygen (hypoxia). At any moment, there is an "ideal"altitude where your body is in balance; most likely this is the last elevation at which you slept. Extending
above this is an indefinite gray zone where your body can tolerate the lower oxygen levels, but to which you are not quite acclimatized. If you get above the upper limit of this zone, there is
not enough oxygen for your body to function properly, and symptoms of hypoxic distress occur - this is AMS.Go too high above what you are prepared for, and you get
sick.

This "zone of tolerance" moves up with you as you acclimatize. Each day, as you ascend, you are acclimatizing to a higher elevation, and thus your zone of tolerance extends that much higher up
the mountain. The trick is to limit your daily upward travel to stay within that tolerance zone.

The exact mechanisms of AMS are not completely understood, but the symptoms are thought to be due to mild swelling of brain
tissue in response to the hypoxic stress. If this swelling progresses far enough, significant brain dysfunction occurs. This brain tissue distress causes a number of symptoms; universally present
is a headache, along with a variety of other symptoms.

The diagnosis of AMS is made when a headache, with any one or more of the following symptoms is present after a recent ascent above 2500 meters (8000
feet):

• Loss of appetite, nausea, or vomiting

• Fatigue or weakness

• Dizziness or light-headedness

• Difficulty sleeping

All of these symptoms may vary from mild to severe. A scoring system has been developed based on the Lake Louise criteria (see below). AMS has been likened to a bad hangover, or worse. However,
because the symptoms of mild AMS can be somewhat vague, a useful rule-of-thumb is:

if you feel unwell at altitude, it is altitude sickness unless there is another obvious explanation (such as diarrhoea). Anyone who goes to altitude can
get AMS.

It is primarily related to individual physiology (genetics) and the rate of ascent; there is no significant effect of age, gender,
physical fitness, or previous altitude experience. Some people acclimatize quickly, and can ascend rapidly; others acclimatize slowly and have trouble staying well even on a slow ascent. There
are factors that we don't understand; the same person may get AMS on one trip and not another despite an identical ascent itinerary. Unfortunately, no way has been found to predict who is likely
to get sick at altitude.

HIGH ALTITUDE CEREBRAL OEDEMA (HACE)

AMS is a spectrum of illness, from mild to life-threatening. At the "severely ill" end of this spectrum is High Altitude Cerebral Oedema; this is when the
brain swells and ceases to function properly. HACE can progress rapidly, and can be fatal in a matter of a few hours to one or two days. Persons with this illness are often confused, and may not
recognize that they are ill.

The hallmark of HACE is a change in the ability to think. There may be confusion, changes in behaviour, or lethargy. There is also a characteristic loss
of coordination. This is a staggering walk that is similar to the way a person walks when very intoxicated on alcohol. This loss of coordination may be subtle, and must be
specifically tested for. Have the sick person do a straight line walk. Draw a straight line on the ground, and have them walk along the line, placing one foot immediately in front of the other,
so that the heel of the forward foot is right in front of the toes behind. Try this yourself. You should be able to do it without difficulty. If they struggle to stay on the line (the high-wire
balancing act), can not stay on it, fall down, or can not even stand up without assistance, they fail the test and should be presumed to have HACE.

Immediate descent is the best treatment for HACE. This is of the utmost urgency, and cannot wait until morning (unfortunately, HACE
often strikes at night). Delay may be fatal. The moment HACE is recognized is the moment to start descent. A 500-1000 meter descent is a good starting point. Other treatments include oxygen, hyperbaric bag, and Dexamethasone. These are usually used as a temporary measure until descent can be achieved.

People with HACE usually survive if they descend soon enough and far enough, and usually recover completely. The staggering gait may persist for days after descent. Once recovery has been
complete a cautious re-ascent is acceptable.

HIGH ALTITUDE PULMONARY OEDEMA (HAPE)

Another form of severe altitude illness is High Altitude Pulmonary Edema, or fluid
in the lungs. Though it often occurs with AMS, it is not felt to be related and the classic signs of AMS may be absent. Signs and
symptoms of HAPE may include any of the following:

• Extreme fatigue

• Breathlessness at rest

• Fast, shallow breathing

• Cough, possibly productive of frothy or pink sputum

• Gurgling or rattling breaths

• Chest tightness, fullness, or congestion

• Blue or gray lips or fingernails

• Drowsiness

HAPE usually occurs on the second night after an ascent, and is more frequent in young, fit climbers or trekkers.

In some persons, the hypoxia of high altitude causes constriction of some of the blood vessels in the lungs, shunting all of the blood through a limited number of vessels that are not
constricted. This dramatically elevates the blood pressure in these vessels and results in a high-pressure leak of fluid from the blood vessels into the lungs. Exertion and cold exposure can also
raise the pulmonary blood pressure and may contribute to either the onset or worsening of HAPE. Immediate descent is the treatment of choice for
HAPE; unless oxygen is available delay may be fatal. Descend to the last elevation where the victim felt well upon awakening. Descent may be complicated by extreme fatigue
and possibly also by confusion (due to inability to get enough oxygen to the brain); HAPE frequently occurs at night, and may worsen with
exertion. These victims often need to be carried.

It is common for persons with severe HAPE to also develop HACE, presumably due to the extremely low levels of oxygen in their blood (equivalent to a continued rapid ascent).

HAPE resolves rapidly with descent, and one or two days of rest at a lower elevation may be adequate for complete recovery. Once the symptoms have fully resolved, cautious re-ascent is
acceptable.

HAPE can be confused with a number of other respiratory conditions: High Altitude Cough and Bronchitis are both characterized by a persistent cough with or without sputum production. There is no
shortness of breath at rest, no severe fatigue. Normal oxygen saturations (for the altitude) will be measured if a pulse oximeter is available.

Pneumonia can be difficult to distinguish from HAPE. Fever is common with HAPE and does not prove the patient has pneumonia. Coughing up green or yellow sputum may occur with HAPE, and both can
cause low blood levels of oxygen. The diagnostic test (and treatment) is descent - HAPE will improve rapidly. If the patient does
not improve with descent, then consider antibiotics. HAPE is much more common at altitude than pneumonia, and more dangerous; many climbers have died of HAPE when they were mistakenly treated for
pneumonia. Asthma might also be confused with HAPE. Fortunately, asthmatics seem to do better at altitude than at sea-level. If you think it is asthma, try asthma medications, but if the person
does not improve fairly quickly assume it is HAPE and treat it accordingly.

TREATING ACUTE MOUNTAIN SICKNESS

The mainstay of treatment of AMS is rest, fluids, and mild analgesics: acetaminophen (paracetamol), aspirin, or ibuprofen. These
medications will not cover up the symptoms. The natural progression for AMS is to get better, and often simply resting at the altitude at which you became ill is adequate treatment. Improvement
usually occurs in one or two days, but may take as long as three or four days. Descent is also an option, and recovery will be quite rapid. Altitude headaches are usually nasty, persistent, and
frequently there are other symptoms of AMS; they tend to be frontal (but may be anywhere), and may worsen with bending over. However, there are other causes of headaches, and you can try a simple
diagnostic/therapeutic test. Dehydration is a common cause of headache at altitude. Drink one liter of fluid, and take some acetaminophen or one of the
other analgesics listed above. If the headache resolves quickly and totally (and you have no other symptoms of AMS) it is very unlikely to have been due to AMS.

Acetazolamide (Diamox®) is a medication that forces the kidneys to excrete bicarbonate, the base form of carbon dioxide; this
re-acidifies the blood, balancing the effects of the hyperventilation that occurs at altitude in an attempt to get oxygen. This reacidification acts as a respiratory stimulant, particularly at
night, reducing or eliminating the periodic breathing pattern common at altitude. Its net effect is to accelerate acclimatization. Acetazolamide is not a magic bullet, cure of AMS is not
immediate. It makes a process that might normally take about 24-48 hours speed up to about 12-24 hours.

Acetazolamide is a sulfonamide medication, and persons allergic to sulfa medicines should not take it. Common side effects include numbness, tingling, or vibrating sensations in hands, feet, and
lips. Also, taste alterations, and ringing in the ears. These go away when the medicine is stopped. Since Acetazolamide works by forcing a bicarbonate diuresis, you will urinate more on this
medication. Uncommon side effects include nausea and headache. A few trekkers have had extreme visual blurring after taking only one or two doses of Acetazolamide; fortunately they recovered
their normal vision in several days once the medicine was discontinued.

Acetazolamide:

For treatment of AMS: We recommend a dosage of 250 mg every 12 hours. The medicine can be discontinued once symptoms resolve.
Children may take 2.5 mg/kg body weight every 12 hours.

For Periodic Breathing: 125 mg about an hour before bedtime. The medicine should be continued until you are below the altitude where
symptoms became bothersome.

Dexamethasone (Decadron®) is a potent steroid used to treat brain oedema. Where as Acetazolamide treats the problem (by accelerating
acclimatization), dexamethasone treats the symptoms (the distress caused by hypoxia). Dexamethasone can completely remove the symptoms of AMS in a few
hours, but it does not help you acclimatize. If you use Dexamethasone to treat AMS you should not go higher until the next day, to be sure the medication has worn off and is
not hiding a lack of acclimatization. Side effects include euphoria in some people, trouble sleeping, and an increased blood sugar level in diabetics.

Dexamethasone Use & Dosage:

For treatment of AMS: Two doses of 4 mg, 6 hours apart. This can be given orally, or by an injection if the patient is vomiting.
Children may be given 1 mg/kg of body weight, up to 4 mg maximum; a second dose is given in 6 hours. Do not ascend until at least 12 hours after the last dose, and then only if there are no
symptoms of AMS.

Oxygen

AMS symptoms resolve very rapidly (minutes) on moderate-flow oxygen (2-4 litres per minute, by nasal cannula). There may be rebound
symptoms if the duration of therapy is inadequate - several hours of treatment may be needed. In most high altitude environments, oxygen is a precious commodity, and as such is usually reserved
for more serious cases of HACE and HAPE.

LAKE LOUISE SCORE

There have been several scoring systems used to diagnose and quantify mountain sickness in altitude research, most consisting of questionnaires and some with an additional examination by a
physician. Some such as the Environmental Symptom Questionnaire (ESQ) are long as 67 questions and an attempt has been made to simplify and standardise a scoring system to enable easy comparisons
of results between studies. The Lake Louise Score is such a system arising from consensus meetings in Lake Louise in Canada in 1991 and 1993. Although primarily developed for research use, it is
short, simple format, which is easy to complete in difficult situations, has led to its adoption by general trekkers and mountaineers. It is sensitive
enough to detect AMS whilst having sufficient specificity not to lead to undue over diagnosis. It is however important to realise that all scoring systems can over diagnose AMS. A hangover or flu
for instance will give a positive AMS score even at sea level, so it is important to use them in the context of a recent rise in altitude and to take allowance of any confounding
illness.

Calculating the Lake Louise Acute Mountain Sickness (AMS) Score

Add up the responses to each of the questions of the self-report score (Questions 1-5). A diagnosis of AMS is based on a recent rise in altitude, the presence of a headache with the presence of
at least 1 other symptom, and a total score of at least 3 (some researchers use a threshold score of 4)

AMS = Altitude Gain AND Headache AND at least 1 other symptom AND a total score of 3 or more

Record of Altitudes reached day-by-day (number the days), indicate the maximum altitude during the day and the sleeping altitude.

NOTES:

• The table has been redesigned to help the process of recording become quicker and easier

• The questionnaires are designed to be completed as a self assessment by each individual at breakfast each morning. This should take no more than 5 minutes

• Start the survey on the first day at or above 3000m – label day 1, 2 etc. Please also complete one copy of the itinerary for that period giving change in sleeping altitude and highest point
reached that day.

It is effectively a screening tool, to assist the individual, or alert the leader that there is a potential problem. It is not a substitute for experience common sense etc. It allows the leader
to accurately assess 25 individuals at breakfast in a couple of minutes (if they self assess) and then concentrate on say 3 individuals who score 3 or more.

ALTITUDE SICKNESS FLOW CHART

Please refer to Dr. Tashi Thinles original paper in .pdf

COLD WATER EMERSION

When plunged into cold water, the first hazards to contend with are panic and shock. The initial shock can place severe strain on the body, producing instant cardiac arrest. Survivors of cold
water accidents have reported their breath driven from them on first impact with the water. Should your face be in the water during that first involuntary gasp for breath, it may well be water
rather than air. Total disorientation may occur after cold water immersion. Persons have reported "thrashing helplessly in the water" fort hirty seconds or more until they were able to get their
bearings.

Immersion in cold water can quickly numb the extremities to the point of uselessness. Cold hands cannot fasten the straps of a lifejacket, grasp a thrown rescue line, or hold on to an over-turned
boat. Within minutes, severe pain clouds rational thought. And, finally, hypothermia (exposure) sets in, and without rescue and proper first aid treatment, unconsciousness and death. Normal body
temperature of course, is 98.6 F. Shivering and the sensation of cold can begin when the body temperature lowers to approximately 96.5. Amnesia can begin to set in at approximately 94,
unconsciousness at 86 and death at approximately 79 degrees.

Cold water robs the body's heat 32 times faster than cold air. If you should fall into the water, all efforts should be given to getting out of the water by the fastest means possible. Physical
exercise such as swimming causes the body to lose heat at a much faster rate than remaining still in the water. Blood is pumped to the extremities and quickly cooled. Few people can swim a mile
in fifty degree water. Should you find yourself in cold water and are not able to get out, you will be faced with a critical choice - to adopt a defensive posture in the water to conserve heat
and wait for rescue, or attempt to swim to safety.

Should you find yourself in the water, avoid panic. Air trapped in clothing can provide buoyancy as long as you remain still in the water. Swimming or treading water will greatly increase heat
loss and can shorten survival time by more than 50%. The major body heat loss areas are the head, neck, armpits, chest and groin. If you are not alone, huddle together or in a group facing each
other to maintain body heat.

First Aid Considerations For Cold Water Victims

Treatment for hypothermia depends on the condition of the person. Mild hypothermia victims who show only symptoms of shivering and are capable of rational conversation may only require removal of
wet clothes and replacement with dry clothes or blankets. In more severe cases where the victim is semi-conscious, immediate steps must be taken to begin the re-warming process.

Get the person out of the water in an horizontal position and into a warm environment. Remove the clothing only if it can be done with a minimum of movement of the victim's body. Do not massage
the extremities. Lay the semi-conscious person face up, with the head slightly lowered, unless vomiting occurs. The head down position allows more blood to flow to the brain. Warm humidified
oxygen should be administered by facemask if available.

Immediately attempt to re-warm the victim’s body core. If available, place the person in a bath of hot water at a temperature of 105 to 110 degrees. It is important that the victim's arms and
legs be kept out of the water to prevent "after-drop". After-drop occurs when the cold blood from the limbs is forced back into the body resulting in further lowering of the core temperature.
After-drop can be fatal. If a bath is not available, apply hot, wet towels or blankets to the victim's head, neck, chest, groin, and abdomen. Do not warm the arms or legs. If nothing else is
available, a rescuer may use their own body heat to warm a hypothermia victim.

Never give alcohol to a hypothermia victim.

Some Important Facts To Remember

Most persons recovered in cold water "near" drowning cases show the typical symptoms of death:

90º - 86ºF: Shivering stops, exposed skin blue of puffy, muscle coordination very poor, inability to walk, confusion, incoherent/irrational behaviour, but may be able to maintain posture and
appearance of awareness.

• If you can't get a radial pulse at the wrist it indicates a core temp below 90 - 86 degrees F

• The person may be curled up in a fetal position. Try to open their arm up from the fetal position, if it curls back up, the person is alive. Dead muscles won't contract only live muscles.

Treating Hypothermia

The basic principles of re-warming a hypothermic victim are to conserve the heat they have and replace the body fuel they are burning up to generate that heat. If a person is shivering, they have
the ability to re-warm themselves at a rate of 2 degrees C per hour.

Mild - Moderate Hypothermia

Reduce Heat Loss:

• Additional layers of clothing

• Dry clothing

• Increased physical activity

• Shelter

Add Fuel & Fluids:

It is essential to keep a hypothermic person adequately hydrated and fueled.

Food types:

• Carbohydrates - quickly released into blood stream for sudden brief heat surge - theseare the best to use for quick energy intake especially for mild cases of hypothermia

• Proteins - slowly released - heat given off over a longer period

• Fats - slowly released but are good because they release heat over a long period, however, it takes more energy to break fats down into glucose - also takes more water to break down fats
leading to increased fluid loss

Food intake:

• Hot liquids - calories plus heat source

• Sugars

Things to avoid:

• Alcohol - a vasodilator - increases peripheral heat loss

• Caffeine - a diuretic - causes water loss increasing dehydration

• Tobacco/nicotine - a vasoconstrictor, increases risk of frostbite

Add Heat:

• Fire or other external heat source

• Body to body contact

Severe Hypothermia

Reduce Heat Loss:

• Hypothermia Wrap: The idea is to provide a shell of total insulation for the patient. No matter how cold, patients can still internally re-warm themselves much more efficiently
than any external re-warming. Make sure the patient is dry. Use multiple sleeping bags, wool blankets, wool clothing, include an aluminium "space" blanket to help prevent radiant heat loss.

Add Fuel & Fluids:

Warm Sugar Water - for people in severe hypothermia, the stomach has shut down and will not digest solid food but can absorb water and sugars. Give a dilute mixture of warm water
with sugar every 15 mins. Dilute Jelly works best since it is part sugar and part protein. This is absorbed directly into the blood stream providing the necessary calories to allow the person to
re-warm themselves.

• Urination - A full bladder results in body heat being used to keep urine warm rather than vital organs. Once the person has urinated, body heat will be used to maintain the
temperature of vital organs.

Add Heat:

Heat can be applied to transfer heat to major arteries - at the neck for the carotid, at thearmpits for the brachial, at the groin for the femoral, at the palms of the hands for the arterial
arch.

The core temperature can actually decrease during re-warming. This is caused by peripheral vessels in the arms and legs dilating if they are re-warmed. This dilation sends this cold, stagnate
blood from the periphery to the core further decreasing core temperature which can lead to death. Afterdrop can best be avoided by not re-warming the periphery. Re-warm the core only. Do not
expose a severely hypothermic victim to extremes of heat.

CPR & Hypothermia

When a person is in severe hypothermia they may demonstrate all the accepted clinical signs of death:

• Cold

• Blue skin

• Fixed and dilated pupils

• No discernable pulse

• No discernable breathing

• Comatose & unresponsive to any stimuli

• Rigid muscles

But they still may be alive in a "metabolic freezer" and can be revived. Your job is to rewarm the person and do CPR if indicated. A hypothermic victim is never cold and dead only warm and dead.

Make sure you do a complete assessment of heart rate before beginning CPR. Instituting CPR at this point may lead to life-threatening arrythmias. Check the carotid pulse for a longer time period
to ascertain if there is a slow heartbeat. Be sure the pulse is absent before beginning CPR. You will need to continue to do CPR as you re-warm the person.

In addition, blowing warm air into the persons lungs may assist in internal re-warming.

Cold Injuries

Tissue temperature in cold weather is regulated by two factors, the external temperature and the internal heat flow. All cold injuries described below are intimately connected with the degree of
peripheral circulation. As peripheral circulation is reduced to prevent heat loss to the core these conditions are more likely to occur.

Factors influencing cold injuries:

• Low ambient temperature

• Wind chill - increases rate of freezing dramatically

• Moisture - wet skin freezes at a higher temp than dry

• Insulation

• Contact with metal

• Exposed skin

• Vasodilation

• Vasoconstriction

• Previous cold injuries

• Constricting garments

• Local pressure

• Cramped position

• Body type

• Dehydration•

Women do better in cold than men (greater subcutaneous body fat)

• Caloric intake

• Alcohol

• Caffeine, nicotine

When a hand or foot is cooled to 59 degrees F, vasoconstriction and minimal blood flow occur. If cooling continues to 50 degrees, vasoconstriction is interrupted by periods of vasodilation with
an increase in blood and heat flow. This response recurs in 5-10 minute cycles to provide some protection from cold. Prolonged, repeated exposure increases this response and offers some degree of
acclimatization.

As tissue begins to freeze, ice crystals are formed within the cells. As intracellular fluids freeze, extracellular fluid enters the cell and there is an increase in the levels of extracellular
salts due to the water transfer. Cells may rupture due to the increased water and/or from tearing by the ice crystals. Do not rub tissue; it causes cell tearing from the ice crystals. As the ice
melts there is an influx of salts into the tissue further damaging the cell membranes. Cell destruction results in tissue death and loss of tissue. Tissue can't freeze if the temperature is above
32 degrees F. It has to be below 28 degrees F because of the salt content in body fluids. Distal areas of the body and areas with a high surface to volume ratio are the most susceptible (e.g.
ears, nose, fingers and toes):

• Re-warm the area gently, generally by blowing warm air on it or placing the area against a warm body part

• Do not rub the area - this can damage the effected tissue by having ice crystals tear the cell

Frostbite:

• Skin is white and "wooden" feeling all the way through

• Superficial frostbite includes all layers of skin

• Numbness

• Deep frostbite can include freezing of muscle and/or bone, it is very difficult to re-warm the appendage without some damage occurring

Treatment:

• Superficial frostbite may be rewarmed as frostnip if only a small area is involved

• If deep frostbite, use the rewarming technique

Rewarming of Frostbite:

• Rewarming is accomplished by immersion of the effected part into a water bath of 105-110 degrees F. No hotter or additional damage will result. This is the temperature which is warm to your
skin. Place the appendage in the water and continue to monitor the water temperature. This temperature will drop so that additional warm water will need to be added to maintain the 105-110
degrees. Do not add this warm water directly to the injury. The water will need to be circulated fairly constantly to maintain even temperature. The effected appendage should be immersed for
25-40 minutes. Thawing is complete when the part is pliable and colour and sensation has returned. Once the area is re-warmed, there can be significant pain. Discontinue the warm water bath when
thawing is complete.

• Do not use dry heat to re-warm. It cannot be effectively maintained at 105-110 degrees and can cause burns further damaging the tissues.

• Once re-warming is complete the injured area should be wrapped in sterile gauze and protected from movement and further cold.

• Once a body part has been re-warmed it cannot be used for anything. Also it is essential that the part can be kept from refreezing. Refreezing after re-warming causes extensive tissue damage
and may result in loss of tissue. If you cannot guarantee that the tissue will stay warm, do not re-warm it. Once the tissue is frozen the major harm has been done. Keeping it frozen will not
cause significant additional damage.

Special Considerations for Frostbite:

• If the person is hypothermic and frostbitten, the first concern is core re-warming. Do not re-warm the frostbitten areas until the core temp approaches 96 degrees.

• No alcohol or smoking

Immersion Foot

Immersion foot (trench foot) is a process similar to chillblains. It is caused by prolonged exposure of the feet to cool, wet conditions. This can occur at temperatures as high as 60 degrees F if
the feet are constantly wet. Wet feet lose heat 25x faster than dry, therefore the body uses vasoconstriction to shut down peripheral circulation in the foot to prevent heat loss. Skin tissue
begins to die because of lack of oxygen and nutrients and due to build up of toxic products. The skin is initially reddened with numbness, tingling pain, and itching then becomes pale and mottled
and finally dark purple, grey or blue. The effected tissue generally dies. In severe cases Immersion foot can involve the toes, heels, or the entire foot. If circulation is impaired for > 6
hours there will be permanent damage to tissue. If circulation is impaired for > 24 hours the victim may lose the entire foot. Immersion Foot causes permanent damage to the circulatory system
making the person more prone to cold related injuries in that area.

Treatment and Prevention of Immersion foot:

• Includes careful washing and drying of the feet, gentle re-warming and slight elevation. Since the tissue is not frozen as in severe frostbite it is more susceptible to damage by walking on it.
Pain and itching are common complaints. Give Ibuprofen or other pain medication.

• Keep feet dry by wearing appropriate footwear. Check your feet regularly to see if they are wet. If your feet get wet, stop and dry your feet and put on dry socks. Periodic air drying will also
help. Change socks at least once a day and do not sleep with wet socks. Foot powder can help.

• The cold exposure causes damage to the peripheral capillary beds, this damage is permanent and the redness and itching will return with exposure

Snowblindness:

• Sunburn of the eyes

• Prevention by wearing good sunglasses with side shields or goggles

Symptoms:

• Occur 8-12 hours after exposure

• Eyes feel dry and irritated, then feel as if they are full of sand, moving or blinking becomes extremely painful, exposure to light hurts the eyes, eyelids may swell, eye redness, and excessive
tearing